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r Ap a KIII Be P„Itgt�sed When Submitted Properly Completed.Be Sure To Sign The Applicatio <br /> FOR OFFICE US �� \--'' Cp- APPLICATION <br /> Qj�yiin-Transferable, Revocable,Suspendable) <br /> fm PUMP HEALTH PERMIT PUMP&WELL <br /> (COMPLETE IN TRIPLICATE) G,P� �� ` WATER QUALITY <br /> Appl ication is hereby made to theaquin Local Health District fora permit to construct and/or install the work,herein described.This application is <br /> made in compliance with SaryJpragyilyCoun r �n e�g2 and the,94es and regulations of the San,J� in � h District. <br /> Exact Site Address ` 7/ (O [� j� 7V /� City/Town <br /> Owner's Name / 575 <br /> Phone <br /> Address /¢ L City <br /> Contractor's Name ��� 60 JJ License# Business Phgn <br /> Contractor's Address Emergency Phone 6 6 <br /> Is Certificate of Workman's Compensation Insurance on File With SJLHD? Yes No <br /> TYPE OF WORK (CHECK): NEW WELL 1:1 DEEPEN ❑ RECONDITION El DESTRUCTION❑ - <br />, WELL CHLORINATION ❑ WELL ABANDONMENT ❑ OTHER ❑ PUMP INSTALLATION ❑ PUMP REPAIR❑ <br /> REPLACEMENT❑ <br /> DISTANCE TO NEAREST: Septic Tank Sewer Lines Pit Privy <br /> Sewage Disposal Field Cesspool/Seepage Pit Other <br /> Property Line . Private Domestic Well Public Domestic Well --T <br /> INTENDED USE TYPE OF WELL <br /> ❑ INDUSTRIAL ❑ CABLE TOOL Dia. of Well Excavation <br /> ❑ DOMESTIC/PRIVATE ❑ DRILLED Dia. of Well Casing <br /> ❑ DOMESTIC/PUBLIC ❑ DRIVEN Gauge of Casing <br /> ❑ IRRIGATION ❑ GRAVEL PACK Depth of Grout Seal <br /> ❑ CATHODIC PROTECTION ❑ ROTARY Type of Grout <br /> ❑ DISPOSAL ❑ OTHER Other Information <br /> ❑ GEOPHYSICAL Surface Seal Installed By: <br /> PUMP INSTALLATION: Contractor <br /> Type of Pump <br /> H.P. <br /> PUMP REPLACEMENT: ❑ State Work Done <br /> PUMP REPAIR: ❑ State Work Done <br /> DESTRUCTION OF WELL: Well Diameter Appr, <br /> Describe Material and Procedure 7 <br /> Y^ i <br /> I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County <br /> ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. <br /> Home owner or licensed agent's signature certifies the following:"I certify that in the performance of the work for which this permit <br /> is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California." <br /> Contractor's hir' rsub-contracting signature certifies the following:" rtify that in the performance of the work forwhich this <br /> permit I shall emplo pers s subject to workman's com ation laws of California." <br /> I IIIc spectio Tio to rou ' and a final insp tion. } <br /> Signed X <br /> Date <br /> Tii Y�J <br /> : <br /> (Draw Plot Pl on Reverse Side) <br /> PHASE <br /> FO EPARTMENT USE ONLY Application Accepted By CA <br /> Date O <br /> Additional Comments: <br /> 4 <br /> Phase II Grout Inspectio Phase III Final Inspection <br /> Inspection By Date Inspection By Date <br /> Fee Is Due: ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH ❑ January 1 &Received By January 31 ❑ July 1 &Received By July 3T <br /> BILLING REMITTANCE $ _REM IT <br /> BASE EXPLANATION AMOUNT DUE CHECKED <br /> DATE DATE REMITTED AMOUNT <br /> FEE G� <br /> LESS I <br /> PRORATION <br /> PLUS <br /> PENALTY <br /> OTHER <br /> i <br /> OTHER <br /> 53 <br /> a151"1d } <br /> Received by • Date Receipt N. .Per-mil No. lissuanceiDate Mailed Delivered .i <br /> APPLICANT—RETURN ALL COPIES T0: ENVIRONMENTAL HEALTH PERMIT/SERVICES <br /> �__ f661 E.HA2ELTON AVE.,AYEP.O.Boa 2069 STOCKTON,CA 95201 <br />